Embed Size (px)
Citation preview
Infection Control Orientation Course
Things you need to know
Infection Prevention and
Control Handout
Prepared By:
KKUH Infection Control Department
1
2
TABLE OF CONTENTS
TITLE PAGES
I INTRODUCTION 4
Infection Control Flow Chart 5
II Standard Precaution 6
a. Hand Hygiene 7
b. Gloves 13
c. Gown 16
d. Facial Protection 17
e. Mask 18
Sequence of Donning Personal Protective Equipment 20
f. Safe Injection Practices 21
g. Patient Care Equipment/ Devices 21
h. Environmental Control 22
Blood and Body Fluid Spillage Management 24
i. Worker Safety 25
j. Textile and Laundry 25
k. Patient Placement/ Transport 26
l. Respiratory Hygiene/ Cough Etiquette 27
m. Infection Control Practices for Lumbar Puncture 28
III Definition of Infection 29
Chain of Infection 30
Device Related Infection 31
IV Isolation 33
Airborne Isolation 34
Droplet Isolation 40
Contact Isolation 46
Protective Isolation 51
Empiric Isolation 52
3
TABLE OF CONTENTS
TITLE PAGES
V Management of Occupational Exposure 53
Blood and Body Fluid Exposure 53
Tuberculosis 58
Varicella 59
VI Cleaning, Disinfection, Sterilization in HealthCare Setting 61
Spaulding System 63
Cleaning Medical Instrument 65
Disinfection 66
Sterilization 70
VII Waste Management 71
VI MOH Notification 78
IX REFERENCES 80
About Infection Control Department
• Vision
To be a leading center expressing excellence in infection
prevention and control in Saudi by striving consistently to reduce infection
rate to the lowest possible level and promoting a safe environment for
patients and Health Care Workers (HCWs).
• Mission
Implement the recommended infection control guidelines
throughout continuous care on the basis of hospital surveillance,
education and training of Health Care Workers (HCW), promoting research
and continuous quality improvement.
• Values
• a. Islamic Ethic Code
• b. Excellence
• c. Teamwork
• d. Honesty
• e. Transparency and accountability
• f. Lifelong learning
Infection Prevention and Control continues to be a hospital
priority. Infection Control Department ( ICD )provide expert
infection prevention advice and support.
4
*Infection Control Committee
Consist of representative from all hospital department. Conduct
meeting, discussing infection rate, and authorized new guidelines and
IPP.
INFECTION CONTROL DEPARTMENT FLOW CHART
Responsibilities of Infection Control Department (ICD):
a. Minimize Hospital Acquired Infection
b. To provide healthy environment for patients, visitors, and health care personnel (HCP).
c. Education
d. Coordinates with MOH and implements its regulations
e. Healthcare Workers Immunization and Post-exposure Prophylaxis upon exposure to Infectious diseases in cooperation with Occupational Health.
f. Surveillance following National Health and Safety Network (NHSN) definition and surveillance for reporting hospital associated infection
g. Outbreak Management
h. Healthcare Workers Infectious Waste Management
i. Implementing antimicrobial committee recommendation
j. Product Evaluation
5
Standard Precautions are guidelines developed to prevent the transmission of
infection during care for ALL patients regardless of their infectious status.
It is a group of practices meant to reduce the risk of transmission of pathogens.
Standard Precautions apply to the following:
Blood.
All body fluids, secretions and
excretions except sweat .
Non-intact skin.
Mucous membranes
1. Hand Hygiene
2. GLOVES
3. GOWN
4. GOGGLES/ Face Protection
5. MASK
6. Safe Injection Practices
7. Patient Care Equipment/ Devices
8. Environmental Control
9. Worker Safety
10. Textile and Laundry
11. Patient Placement and Transport
12. Respiratory Hygiene / Cough
Etiquette
13. Infection Control Practices for Lumbar
Puncture
Elements of Standard Precaution
6
II. STANDARD PRECAUTION
HAND HYGIENE is a major component of standard precautions and one of
the most effective method to prevent transmission of pathogens associated with
health care.
1. HAND HYGIENE
Why should we clean our hands?
Healthcare-associated pathogens are most
often transmitted from patient to patient
through the hands of healthcare workers.
Hand Hygiene is the single most important
measure for preventing the spread of
microorganisms in healthcare settings.
What are our hands carrying?
Resident Flora: Part of body’s natural defence mechanism
• Deep seated.
• Difficult to remove.
• Associated with infection following surgery/invasive
procedures.
Transient Flora: Superficial
• Transferred with ease to and from hands.
• Important cause of cross infection.
• Easily removed with good hand hygiene.
7
• Healthcare Personnel can get 100s to 1000s of bacteria on their hands by doing simple tasks like:
• pulling patients up in bed • taking a blood pressure or pulse • touching a patient’s hand • touching the patient’s gown or bed sheets • touching equipment like bedside rails, over bed tables, IV pumps
Many Personnel Don’t Realize When They
Have Germs on Their Hands:
• Patients often carry resistant bacteria on many areas of their skin, even without wounds or broken skin.
Patients Often Carry Resistant Bacteria on Their Skin:
HAND HYGIENE
*The Figure shows the percent of patients with (MRSA) who carry the organism on the skin under their arms, on their hands or wrists, or in the groin area
Hand Hygiene: Not a New
Concept:
Since 1840, Semmelweis noticed the
great effect HH of in decreasing rate
of infection. He found that the
maternal mortality rate due to post-
partum haemorrhage has been
dramatically reduced and the only
Intervention: was Hand scrub with
chlorinated lime solution.
Does Hand Hygiene Reduce the Spread of Microorganisms in
Healthcare Settings?
In a scientific study performed in a hospital nursery
• 1/2 of the nurses did not wash their hands between patient contacts. • 1/2 of the nurses washed their hands with an antimicrobial soap between
patient contacts
Babies cared for by nurses who did not wash their hands acquired S. aureus significantly more often than babies cared for by nurses who washed their hands with an antimicrobial soap.
8
WHO “My five (KEY)
moments for Hand
Hygiene”
WHY? To protect the patient against colonization
& exogenous infection.
Examples before :
shaking hands,
helping a patient to move around,
applying oxygen mask, giving physiotherapy
taking pulse, blood pressure, chest auscultation, abdominal palpation,
WHY? To protect the patient against his own germs.
Examples before:
brushing the patient's teeth,
skin lesion care, wound dressing, subcutaneous injection
catheter insertion, opening a vascular access system or a draining
system,
preparation of food, medication.
WHY? To protect you and the environment (after glove removal)
Examples after :
brushing the patient's teeth,, secretion aspiration
skin lesion care, wound dressing, subcutaneous injection
drawing and manipulating any fluid sample, opening a draining system, endotracheal tube insertion and removal
Clearing- up urines, faeces, vomit,
WHY? To protect you & the environment
Examples after:
shaking hands,
helping a patient to move around.
giving physiotherapy
taking pulse, blood pressure, chest auscultation,
abdominal palpation,
applying oxygen mask
WHY? To protect you & the environment
Examples after :
changing bed linen, with the patient out of the bed
monitoring alarm
holding a bed rail
Clearing the bedside table
HAND HYGIENE
9
What are types of Hand Hygiene?
2. HAND RUB using alcohol rub/ gels
For 20 TO 30 seconds
1. HAND WASHING using plain soap and
water or disinfectant soap, e.g., soap containing
Chlorhexidine
For 40 TO 60 seconds
3. HAND SCRUB first scrub will take about
5 minutes and subsequent one ranging from
2-3 minutes. Attention should be taken to
clean under nails.
Are Alcohol-Based Hand Rubs Really
Effective?
Many published studies have shown that
alcohol-based hand rubs can remove bacteria
from hands more effectively than washing
hands with plain or an antimicrobial soap and
water.
You have to perform hand wash with plain/antimicrobial soap since alcohol is not
beneficial during the following situations:
• Your hands are visibly soiled (dirty).
• Hands are visibly contaminated with blood or body fluids. • When dealing with spore forming organism e.g. Cl. difficile. • Before eating and after using the restroom
HAND HYGIENE
10
• Soap Solution
• Aqueous Antiseptic Solution
• Chlorohexidine
• Povidine Iodine
• Tri closan
• Alcohol hand-rubs, gel & wipes
Tips for perfect clean hands:
Fingernails:
• Should be short, clean, and free from
nail varnish as it harbour micro organisms
that are not easily removed during hand
hygiene.
• Documented evidence of link between
artificial nails and a Pseudomonas
outbreak in a neonatal intensive care unit
in the USA.
Jewellery:
• No Jewellery are recommended to be worn on
the hands & wrists as it become contaminated
during work activities and prevent proper hand
hygiene procedures .
Various Hand Hygiene
Decontaminants
HAND HYGIENE
11
Rub hands palm
to palm.
Rt. palm over left
dorsum with
fingers interlacing
Rub palm to palm
interlacing the fingers
of hands.
Rub the back of the fingers by interlocking the hands.
Rub the thumbs. Rub palms with
finger tips.
STEPS FOR PERFECT HAND RUB
Fill your hand with
enough amount of
alcohol gel
Wet hands with water, apply enough soap to cover all hand surfaces
Rub hands palm to
palm.
Rt. palm over left
dorsum with fingers
interlacing.
Rub palm to palm
interlacing the
fingers of hands
Rub the back of the fingers by interlocking the hands.
Rub the thumbs Rub palms with
finger tips.
Rinse hands with
water and dry
thoroughly with a
single use towel
STEPS FOR PERFECT HAND WASHING
Repeat the steps for
20-30 seconds and
let your hand dry.
Repeat the steps for
40-60 seconds and
let your hand dry.
HAND HYGIENE
12
Personal Protective Equipment (Gown, Gloves, Mask, Eye Protection)
Used to protect mucous membranes, airways, skin, and clothing from
contact with infectious agents
All health care worker should Assess the Risk of exposure to body
substances or contaminated surfaces BEFORE any health care activity.
2. GLOVES
“Hand Hygiene and Medical Glove use”
Remove gloves to perform hand hygiene when an indication occurs while wearing gloves
Discard gloves after each task and clean your hand –gloves may carry germs
Wear gloves only when indicating to Standard and Contact precautions, otherwise they become a major risk for germ transmission
REMINDER: Do not wear the same pair of gloves for the care
of more than one patient.
INDICATION FOR GLOVING
GLOVES ON GLOVES OFF
1) Before a sterile procedure.
2) When anticipating contact with blood
or another body fluid, regardless of
the existence of sterile conditions and
including contact with non-intact skin
and mucous membrane.
3) Contact with a patient (and his/her
immediate surroundings) during
contact precautions. VRE, MRSA, RSV,
MRO, ESBL
1) As soon as gloves are damaged (or non-
integrity suspected)
2) When contact with blood, another body fluid,
non-intact skin and mucous membrane has
occurred and has ended
3) When contact with a single patient and
his/her surroundings, or a contaminated
body site on a patient has ended
4) When there is an indication for hand hygiene.
13
“The Glove Pyramid”
The Glove Pyramid-to aid decision
making on when to wear (and not
wear) gloves
Gloves must be worn according to
STANDARD and CONTACT
PRECAUTIONS
Hand hygiene should be performed
when appropriate regardless of
indication for glove use
GLOVES
14
How to Don Gloves
•Don gloves last
•Select correct type and size
•Insert hands into gloves
•Extend gloves over isolation gown cuffs
How to Remove Gloves (1)
•Grasp outside edge near wrist.
•Peel away from hand,
turning glove inside-out.
•Hold in opposite gloved hand.
How to Remove Gloves (2)
•Slide ungloved finger under
•the wrist of the remaining glove
•Peel off from inside, creating a bag for
both gloves.
•Discard.
GLOVES
15
3. GOWN
Wear to protect skin and prevent soiling of clothing during activities that
are likely to generate splashes or sprays of blood, body fluids, secretions or excretions
Gowns are usually the first piece of PPE to be donned.
Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed upper body areas are protected.
Select appropriate type and size
Opening is in the back
Secure at neck and waist
If gown is too small, use two gowns
Gown #1 ties in front .
Gown #2 ties in back
There should be several gown sizes should be available in a healthcare facility.
Gowns should be removed in a manner that prevents contamination of
clothing or skin .The outer, “contaminated”, side of the gown is turned inward
and rolled into a bundle, and then discarded into a designated container for
waste or linen to contain contamination
Gowns should be removed before leaving the patient care area to prevent possible
contamination of the environment outside the patient’s room
16
How to Don Eye and Face Protection
Position goggles over eyes and secure to the head using the ear pieces or headband.
Position face shield over face and secure on brow with headband.
Allow sufficient peripheral vision,
Must be adjustable to ensure a secure fit
Personal eyeglasses and contact lenses are NOT considered adequate eye protection Eye protection must be comfortable, allow for sufficient peripheral vision, and must be adjustable to ensure a secure fit.
Type of Eye/face protection will be chosen according to work situations and circumstances of exposure with other PPE used. Even if Droplet Precautions are not recommended for the patient, protection for the eyes, nose and mouth , is necessary when it is likely that there will be a splash or spray of blood any respiratory secretions or other body fluids.
2. A face shield to protect mucous membranes of the eyes, nose and mouth during activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions
1. Eye protection (eye visor, goggles) or
4. FACIAL PROTECTION
(Eyes, Nose, and Mouth)
17
Used for the following primary purposes in healthcare settings:
To protect the staff from contact with infectious material from patients e.g., respiratory secretions and sprays of blood or body fluids, consistent with Standard Precautions and Droplet Precautions;
To protect patients from exposure to infectious agents carried in a healthcare worker’s mouth or nose during procedures.
To limit potential dissemination of infectious respiratory secretions of an infected patient or staff .
5. MASKS
HOW TO DON A MASK
1. Place over nose, mouth and chin
2. Fit flexible nose piece over nose
bridge
3. Secure on head with ties or elastic
4. Adjust to fit Place over nose, mouth
and chin
5. Fit flexible nose piece over nose
bridge
6. Secure on head with ties or elastic
*Masks may be used in
combination with goggles / face
shield to protect the mouth,
nose and eyes to provide more
complete protection for the
face
REMOVING A MASK
1. Untie the bottom, then top, tie
2. Remove from face
3. Discard.
SURGICAL MASKS
18
Removing a Particulate Respirator
1. Lift the bottom elastic over your head first
2. Then lift off the top elastic
3. Discard
How to Don a Particulate Respirator
1. Select a fit tested respirator 2. Place over nose, mouth and chin 3. Fit flexible nose piece over nose bridge 4. Secure on head with elastic 5. Adjust to fit 6. Perform a fit check –
• Inhale – respirator should collapse
• Exhale – check for leakage around face
N95 MASK/ RESPIRATOR Used as a part of airborne precautions to prevent inhalation of small particles
that may contain infectious agents transmitted via the airborne route. All hospital staff should be aware about the type and the size of N95 mask that is
suitable for them by informing fit testing. Before wearing the respirator the staff should make ensure that it is well sealed
over his face features by performing well sealed check. The staff will inhale through the mask and notice little collapse. If exhale through the mask the staff will notice little expansion that will prevent the staff to breathe through mask leakage.
N95 mask will be worn outside the patient room (ante-room) and should be
disposed outside the patient room (ante-room). It can be used for whole shift / for 8-12 hours. The staff should be careful that the mask will be contaminated from outside.
MASK
19
SEQUENCE OF DONNING PPE
Gown first.
Mask or respirator.
Goggles or face shield.
Hand Hygiene
Gloves.
Don before contact with the patient, generally before
entering the room.
SEQUENCE OF REMOVING PPE
Gloves.
Hand Hygiene
Face shield or goggles.
Gown.
Mask or respirator.
Hand Hygiene
Where to Remove PPE
At doorway, before leaving patient room or in anteroom.
Remove respirator outside room, after door has been closed.
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
20
Use aseptic technique to avoid contamination of sterile injection equipment: 1. Do not administer medications from a syringe to
multiple patients, even if the needle or cannula on the syringe is changed.
2. Use single-dose vials for parenteral medications whenever possible.
3. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
4. If multi- dose vials must be used, both the needle or cannula and syringe used to access the multi- dose vial must be sterile.
5. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients
6. SAFE INJECTION PRACTICES
Ensure that reusable equipment is not used for the care of another patient until it has been cleaned , reprocessed and maintained appropriately according to the manufacturers’ instructions. Ensure that single use items are discarded properly All such equipment and devices should be handled in a manner that will prevent HCW and environmental contact with potentially infectious material It is important to have a written policies for cleaning and disinfection of patient care equipment.
7. PATIENT CARE EQUIPMENT / DEVICES
21
The removal of adherent visible soil, blood, protein substances (tissue) and other debris from surfaces by mechanical or manual process
• Removes reservoirs of potential pathogenic organisms
• Generally accomplished with water and detergents
CLEANING
The key to cleaning and disinfecting environmental surfaces is the
use of friction (“elbow grease”) to physically remove visible dirt, organic material, and debris, thereby removing microorganisms.
Frequently-touched
surfaces
Less frequently-
touched surfaces
2 Categories of
Environmental
Surfaces Cleaning schedules and procedures should progress from
the least soiled areas to the most soiled and from high surfaces to low ones.
Minimize air and dust turbulence when cleaning to prevent dispersion of fungal spores. (e.g. Aspergillus)
PATIENT CARE AREA Keep housekeeping surfaces visibly clean on regular basis. Clean up spills promptly. Clean and disinfect high-touch surfaces, such as doorknobs, bed rails, light switches, and surfaces in and around toilets on a more frequent schedule. Clean walls, blinds, and window curtains in patient-care areas when visibly soiled or dusty.
PROCEDURE ROOM Clean horizontal surfaces daily Clean patient contact surfaces and floor and spot check for blood and body fluids between each case After last procedure of day, wet vacuum or mop floors with a single use mop and EPA-registered hospital disinfectant.
8. ENVIRONMENTAL CONTROL
22
Surface disinfectant should be approved by environmental protection agency( EPA) .It should be tuberculocidal .
For Special pathogens : MDRO, MRSA , routine cleaning is performed at the end after cleaning non infected areas using a color coded mob.
For Clostridium difficile ( spore forming organisms ) , use hypochlorite – based product for disinfection.
In case of Vancomycin Resistant Enterococci VRE , vigorous cleaning is needed .
TERMINAL CLEANING is done after patient discharge,
before next patient admission
Wear PPE (e.g., gloves, gown), according to the level of anticipated contamination, when handling patient-care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids 3 color code mops
are available:
NO MARK for non
infected areas
YELLOW for
isolated patients
RED for toilet
Clean utility area
should be dedicated
only for clean item,
and dirty utility area
only for dirty item .
Do not mix clean
item with dirty one.
• Discard all disposable items in accordance with the
policy on disposal of infectious wastes.
• Thoroughly clean all horizontal surfaces of furniture,
mattress covers and patient care equipment with a
disinfectant-detergent solution.
• Wet-vacuum or wet-mop all floors with a disinfectant-
detergent solution.
ENVIRONMENTAL CONTROL
23
ALWAYS SEPARATE CLEAN ITEMS FROM
DIRTY ITEMS
For Blood and Body Fluids Spillage: Use chlorine
releasing disinfectant e.g. Household bleach
(5.25% sodium hypochlorite solution) . Use a 1:10
dilution (= 10,000 ppm )
1. In Wet Spillage Granules should be carefully and
evenly sprinkled over the spillage If the Blood Spillage has dried, a dilution of
10,000ppm (parts per million) solution of
sodium hypochlorite is prepared.
2. Cover the spillage with paper towels or white pad, depending on the size of the spillage.
3. Let the disinfectant be in contact with the spillage for a minimum of 2 minutes.(Follow manufacture recommendations ) .
4. After the contact period, the resulting residual waste must be carefully removed using disposable paper towel or scooping receptacle and placed into an yellow, clinical waste disposal bag.
5. Once the residual waste has been removed, the area should be cleaned thoroughly using warm water and a detergent. Domestic service staff could be contacted to clean the area after the spill has been dealt with.
6. All disposable items, including gloves and aprons, must be carefully disposed of into an yellow clinical waste disposal bag.
7. Hands must be decontaminated (e.g. washed & dried followed by an application of alcohol hand rub) after disposing of all contaminated materials.
BLOOD AND BODY FLUID SPILLAGE
MANAGEMENT
ENVIRONMENTAL CONTROL
Dealing with Blood/ Body Fluid Spillage is the responsibility of Area Supervisor
24
*Do not apply chlorine releasing disinfectant
directly onto urine as this may result in rapid
release of toxic levels of chlorine
If there is sharp object, pick it up with
forceps
Health care personnel who have exudative lesions or weeping dermatitis should refrain from all direct [patient care and from handling patient care equipment until the condition resolves.
9.WORKER SAFETY
Remind all health care worker regarding proper care, handling and disposal of sharps and pointed objects
No needle recapping or manipulation
Use of sharp boxes for disposal
Proper use of Personal Protective Equipment (PPE) to protect mucous membranes and non-intact skin from contact with potentially infectious material.
Safe Sharps and Needles. Use of safe sharps and needles available in your area (e.g. retractable needles, needleless connectors.
Immunization. Ensure that all hospital staff received three (3) doses of Hepatitis B Vaccine series which should be taken (at time 0-1month-6month). All vaccinated staff should check their anti-body level to make sure that they are immune.
10. TEXTILE AND LAUNDRY
Soiled textiles, including bedding, towels, and patient or resident clothing may be contaminated with pathogenic microorganisms
Key principles for handling soiled laundry : 1) Not shaking the items or handling them in any way that may aerosolize infectious agents 2) Avoiding contact of one’s body and personal clothing with the soiled items being handled 3) Containing soiled items in a laundry bag or designated bin
*Non-Soiled Linen- BLUE BAG * Soiled Linen (with Blood and Body Fluids) - Water Soluble Transparent Bag
25
11. PATIENT PLACEMENTS /TRANSPORT
1. Patients who have conditions that facilitate transmission of infectious material to other patients (e.g., draining wounds, stool incontinence, uncontained secretions).
2. Patients who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immune-suppression, open wounds, indwelling catheters, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living)
Single patient rooms are preferred when there is a concern about transmission of an infectious agent. When there are only a limited number of single-patient rooms, it is prudent to prioritize them according to the following :
PATIENT PLACEMENT
Cohorting is the practice of grouping
together. Patients who are colonized or
infected with the same organism, to
confine their care to one area and prevent
contact with other patients.
Limit the transport of patients under Transmission Based Precaution to essential purposes, such as diagnostic and therapeutic procedures that cannot be performed in the patient’s room. When transporting the patient ensure to contain any infection using appropriate barriers on the patient (e.g. cover surgical site infection with appropriate dressing, mask the patient who is coughing)
NO NEED FOR THE STAFF TO WEAR PPE IN HOSPITAL CORRIDOR
PATIENT TRANSPORT
Notify healthcare personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission
26
12. RESPIRATORY HYGIENE/ COUGH ETIQUETTE
Applied to health care personnel, patients , visitors and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a healthcare facility.
Person with respiratory symptoms should apply source control measures:
√ Cover nose, mouth when coughing/sneezing with tissue and prompt disposal of used
tissues and
√ Use a surgical masks on the coughing person and
√ Perform hand hygiene after contact with respiratory secretions
1. Education of healthcare facility staff, patients, and visitors. 2. Place acute febrile respiratory symptoms patient at least 1 meter (3 feet) away from others in common waiting areas, if possible. 3. Post visual alert at the entrance to health-care facilities instructing persons with respiratory symptoms to practice respiratory hygiene/cough etiquette. 4. Consider making hand hygiene resources, tissues and masks available in common areas and areas used for the evaluation of patients with respiratory illnesses.
27
13. INFECTION CONTROL PRACTICES FOR
LUMBAR PUNCTURE
Healthcare Infection Control Practices Advisory Committee (HICPAC)
reviewed the evidence and concluded that there is sufficient experience to
warrant the additional protection of a surgical mask for the individual placing a
catheter or injecting material into the spinal or epidural space (e.g., myelogram,
lumbar puncture, spinal anesthesia). Facemasks are effective in limiting the
dispersal of oropharyngeal droplets.
An investigation done by CDC wherein 8 cases of post myelography
meningitis where reported and they found out that cerebral fluid of eight cases yielded
streptococcal spp. Consistent with oropharyngeal flora. Proper preparations where
done and found out that none of the clinician Wore a face mask which likely gives the
explanation for the infection
28
III. Definition of Infection
COMMUNITY ACQUIRED INFECTION
Its an infection that presented or incubating at the time of admission to the hospital at
the first 48-72 hours from admission.
HEALTHCARE ASSOCIATED INFECTION (HAI) (Nosocomial)
An infection that is acquired from the hospital. It is presented after 48 to 72 hours of
admission or within a defined period after hospital discharge according to the disease
incubation period. Each hospital acquired infection has a specific criteria and definition
(Please refer to National Health and Safety Network Hospital Acquired Infection).
Categories of HAI Infection
1. Surgical Site Infection 2. Pneumonia 3. Urinary Tract Infection 4. Bacteremia 5. Device Related Infection a. VAP- Ventilated Associated Pneumonia b. CLABSI- Central Line Blood Stream Associated Infection c. CAUTI- Catheter Associated Urinary Tract 6. Gastro – intestinal Tract Infection 7. Others e.g. skin and subcutaneous , meningitis.
29
INFECTION Entry and multiplication of an infectious agent in the tissues of the host.
COLONIZATION presence and multiplication of microorganisms in or on a host without tissue damage.
INCUBATION PERIOD Time of initial contact with the infectious agent to the appearance of the first symptoms.
The Chain of Infection
30
31
Pneumonia (PNEU) - inflammation of the lung parenchyma- is identified by using a combination of radiologic, clinical and laboratory criteria.
Ventilator: A device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation.
Urinary Tract Infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney.
Indwelling Catheter A drainage tube that is inserted into the urinary bladder through the urethra is left in place, and is connected to a drainage bag (including leg bags), also called a Foley catheter. This does not include condom or straight in-and-out catheters or nephrostomy tubes or suprapubic catheters unless a Foley catheter is also present. This definition includes indwelling urethral catheters that are used for intermittent or continuous irrigation.
Catheter-associated UTIs (CAUTI) occur in a patient with an indwelling urinary catheter on the time of, or within 48 hours before the onset of UTI.
Ventilator-Associated Pneumonia (VAP) Occurs in a patient who is ventilated on the time of, or within 48 hours before the onset of pneumonia.
DEVICE RELATED INFECTIONS
Each hospital acquired infection has a specific criteria and definition (Please refer to National Health and Safety Network Hospital Acquired Infection).
32
Central Line Central line: An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels for the purpose of reporting central-line BSI and counting central-line days in the NHSN system: • Aorta • Pulmonary artery • Superior vena cava • Inferior vena cava • Brachiocephalic veins • Internal jugular veins • Subclavian veins • External iliac veins • Common iliac veins • Femoral veins • In neonates, the umbilical artery/vein.
Nosocomial Blood Stream Infections (BSIs) is typically defined as the demonstration of a recognized pathogen in the blood stream of patient who has been hospitalized for >48 hours.
Primary Bacteremia arises from an occult infection which associated with intravascular devices or administration of contaminated intravenous fluids, hyper alimentation solutions, and blood products or from contaminated transducers.
Only 3-4 % of recognized nosocomial infections are primary Bacteremia.
Secondary Bacteremia: - when a microorganism isolated from the blood stream originated from a nosocomial infection at another site (urinary tract, surgical site, etc.
Central Line-Associated bloodstream infections (CLABSI) Occur in a patient who has a central line at the time of, or within 48 hours before the onset of the BSI.
Bundle of Care A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices at and when performed collectively and reliably, have been proven to improve patient outcomes.
DEVICE RELATED INFECTIONS
33
The separation of a person with infectious disease from contact with other human beings, for the period of communicability.
SYTEMS IN K.S.U.Hs: KKUH & KAUH follows Transmission Based Isolation system and under this system three category currently exist.
IV. ISOLATION
EMPIRIC ISOLATION
Airborne Precaution are used in addition to
Standard Precautions for patients known or suspected to be infected with microorganisms transmitted by relatively small droplet nuclei (<5microns) that remain suspended in the air for long period of time. These nuclei become dispersed widely with air current within a room or a long distance. Airborne transmission occurs when the widely dispersed nuclei containing microorganisms become inhaled by a susceptible host.
AIRBORNE PRECAUTIONS Requirements:
1. Patients Placements: Place the patient in an Airborne Infection Isolation Room (AIIR) that has been constructed with: • Room supplied with negative pressure, which is regularly monitored. • At least 6-12 air exchanges per hour shall be provided. • Exhaust of air shall be directed to the outside. If it is not possible and air will be
returned to the air-handling system or adjacent spaces, all exhaust air should be directed through HEPA filters.
Post the pink “Airborne Precautions” sign to the door with instructions for Health
Care Personnel (HCP) and visitors.
• The AIIR door shall be kept closed when not required for entry and exit. • The room may be supplied with an anti-room for exit and entry. Check and document the negative pressure Daily when room is occupied by a patient required airborne precaution.
Patients requiring the Precautions: • Measles (Rubeola) • Varicella ( Including Herpes Zoster if
disseminated or in immune-compromised patient)
• Tuberculosis (Laryngeal and Pulmonary TB with positive smear for acid fast bacilli ).
34
ISOLATION
2. Respiratory Protection • Wear a fit tested Respiratory Protection (N95 or
higher level respirator) before entering the room of a patient with known or suspected infectious pulmonary or laryngeal tuberculosis.
• To assure good seal the respirator, take a deep
breath. Mask should collapse during inhalation and expand during exhalation.
• Susceptible persons should not enter the room of
patients known or suspected to have measles (Rubeola) or Varicella (chickenpox) if other immune caregiver is available.
• Remove mask AFTER LEAVING patient room in the
Ante-Room if available or outside the patient room.
3. Patient Transport • Limit the movement and transport of the patient from the room to essential
purposes only. • If transport or movement is necessary, minimize patient dispersal of droplet
nuclei by instructing the patient to wear a Surgical Mask. • Healthcare personnel transporting patients who are on Airborne Precautions in
an Open area e.g. hospital corridors, do not need to wear a mask or respirator during transport if the patient is wearing a mask. If in Closed area e.g ambulance; Healthcare worker should wear N-95 mask.
• Inform the receiving department about the type of Precautions for this patient.
4. Linens: • Linen should be handled according to the Standard Precautions and Linen
Laundering policies. Double bagging of linen is not necessary.
5. Patient-Care Equipment: • Providing patients who are on Transmission-Based Precautions with dedicated
noncritical medical equipment (e.g., stethoscope, blood pressure cuff, and electronic thermometer) has been beneficial for preventing transmission.
6. Regulated Medical Waste: Waste is to be handled according to the Standard Precautions and Regular
Medical Waste policies.
7. Cleaning: • Daily, detail, and discharge cleaning is the same for all isolation rooms. Terminal
cleaning can be done after one safety hour without airborne precaution.
35
ISOLATION
Note:
Tuberculosis can be pulmonary and extra-pulmonary. Airborne Precaution is implemented only for Laryngeal / Pulmonary Tuberculosis with sputum smear positive for acid fast bacilli.
For suspected TB patients with smear negative for 3 consequent sample, at least 8 hours in between do not need airborne precaution even if sputum culture came out to be positive. See also discontinuation of isolation.
For patients with diseases transmitted by multiple routes, follow additional isolation requirements in addition to Airborne Precautions. Example: for Varicella zoster (chickenpox) or disseminated Varicella zoster (shingles) Contact Precautions should be followed as well as Airborne Precautions
8. Discontinuing Airborne Precautions Airborne Precautions is discontinued when the patients is no longer considered infectious based on clinical and/or laboratory data.
For example:
• In Pulmonary TB, three (3) consecutive negative sputum smear must be obtained usually after 2 weeks from starting effective treatment. Sample should be obtained least one 8 hours in between. At least one sample should be a morning sample.
• In Varicella patients, all lesions should be crusted to discontinue the isolation.
The isolation is discontinued by the infection control team.
36
ISOLATION
37
ISOLATION
38
ISOLATION
39
ISOLATION
These droplets do not remain suspended in the air; they drop within 3 feet.
Droplet Precautions are used in addition to
Standard Precautions for patients known or suspected to be infected with microorganisms transmitted by relatively large droplet nuclei (>5Microns).
Respiratory droplets are generated when an infected person coughs, sneezes, talk or during procedures such as suctioning, endotracheal intubation, cough induction by chest physiotherapy and cardiopulmonary resuscitation
Examples of such illnesses include:
Invasive Haemophilus influenza type B disease, including meningitis, pneumonia, epiglottis and sepsis
Invasive Neisseria meningitides disease, including meningitis, pneumonia and sepsis.
Other serious bacterial respiratory infections spread by droplet transmission, including:
Diphtheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Streptococcal (group A) pharyngitis, pneumonia or scarlet fever in infants and young children Serious viral infections spread by droplet transmission include:
Adenovirus infection Influenza Mumps Parvovirus B19 Infection Rubella
40
ISOLATION
2. Respiratory Placement In addition to wearing a surgical mask as outlined under
standard precautions, wear a surgical mask when working within 3 feet of the patient.
Wear a mask before entering the room of a patient under Droplet Precautions.
Remove mask BEFORE LEAVING patient room.
1. Patient Placement Place patient in private room (negative pressure room is not indicated ) When a private room is not available, place a patient in a room with other
patients who have infection with the same microorganism but with no other infection. (cohorting)
Post the blue “Droplet Precautions” sign to the door with instructions for Health Care Personnel (HCP) and visitors.
DROPLET PRECAUTIONS Requirements:
3. Patient Transport • Limit the movement and transport of the patient from the room to essential purposes
only • If transport or movement is necessary, minimize patient dispersal of infectious droplet
by instructing the patient to wear surgical mask, and to observe Respiratory Hygiene/Cough Etiquette
• Inform the receiving department about the type of Precautions for this patient.
4 . Linens • Linen should be handled according to the Standard Precautions and Linen
Laundering policies. Double bagging of linen is not necessary.
5. Patient-Care Equipment • Providing patients who are on Transmission-Based Precautions with dedicated
noncritical medical equipment (e.g., stethoscope, blood pressure cuff, and electronic thermometer) has been beneficial for preventing transmission
41
ISOLATION
6. Regulated Medical Waste • Waste is to be handled according to the Standard Precautions and Regular Medical
Waste policies
7. Discontinuing Droplet Precautions • Droplet Precautions is discontinued when the patients is no longer considered
infectious according to communicability of each disease based on clinical and/or laboratory data.
The isolation is discontinued by the infection control team.
NOTE:
Patient with MERS- CoV positive lab result should be under contact and droplet
precautions . Airborne precautions will be implemented in case of performing
aerosolized procedures e.g. bronchial lavage . Isolation will be discontinued 48
hours after recovery of patient signs and symptoms and to have at least one
negative lab result
42
ISOLATION
43
ISOLATION
44
ISOLATION
45
ISOLATION
Contact Transmission can be: Direct-contact Transmission Involves direct contact with infected materials. Indirect- Contact Transmission Involves contact with a contaminated intermediate object, usually inanimate, such as contaminated instruments or surfaces.
In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illness transmitted by contact transmission.
Contact Precautions Requirements: 1. Patient placement Place patient in a private room (negative pressure room is not indicated ). When a private room is not available, place the patient in a room with a patient/s
who has/have infection with the same microorganism but with no other infection (Cohorting).
Post the yellow “Contact Precautions” sign to the door with instructions for Health Care Personnel (HCP) and visitors
Place the appropriate PPE (gloves and gowns) outside the patient room
2. Hand Hygiene
5 moments of Hand Hygiene should be strictly adhered.
Examples of such as illnesses include: - Infective diarrhea in diaper / incontinent patient e.g., Enterohemorrhagic
Escherichia Coli, Hepatitis A, Rotavirus and Shigellosis. - Clostridium Difficile Enterocolitis - Respiratory Syncytial Virus (infants, children, immunocompromised) - Parainfluenza Virus (infants, children) - Herpes Simplex Virus - Impetigo - Multiple Drug Resistant Microorganisms (MDRO) e.g., Methicillin Resistant
Staphylococcus Aureus (MRSA), Escherichia coli Extended Spectrum Betalactamase (ESBL) and Vancomycin Resistant Enterococcus (VRE)
- Streptococcal Group A, Staphylococcus Aureus (major skin wound or burn infection)
- Viral Conjunctivitis
46
Contact Isolation
6. Patient-Care Equipment Providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, and electronic thermometer) has been beneficial for preventing transmission
7. Regulated Medical Waste: Waste is to be handled according to the Standard Precautions and Regular Medical Waste policies
8. Discontinuing Contact Precautions
Maintaining contact precaution is a disease specific duration, according to its communicability. Check the isolation card and consult with infection control nurse prior to discontinuing isolation.
For MDRO Send swab from previously positive sites for culture. 3 negative laboratory results are needed to discontinue the isolation.
5. Linens:
Linen should be handled according to the Standard Precautions and Linen Laundering policies. Double bagging of linen is not necessary
3. Required Personal Protective Equipment (Gloves and Gowns) Wear the gloves and gown before entering the room
of a patient under Contact Precautions. Remove the gloves and gowns BEFORE LEAVING
patient room and dispose it properly.
4. Patient Transport Limit the movement and transport of the patient
from the room to essential purposes only. If transport or movement is necessary, minimize
patient contamination to hospital environment Ensure that contaminated sites (wound, drain) are well contained to prevent transmission of the infection. Clean and disinfect the wheelchair or stretcher with the approved disinfectant.
Inform the receiving department about the type of Precautions for this patient.
47
ISOLATION
- The 1st sample will be sent to the laboratory when patient is clinically improving and 48 hours after cessation of antimicrobial therapy.
- The 2nd sample will be sent if the first sample was negative.
- The 3rd sample will be sent if the 1st and 2nd samples were negative.
48
ISOLATION
49
ISOLATION
50
ISOLATION
PROTECTIVE ISOLATION
• It is implemented for immunocompromised patient.
• Patient is placed in positive pressure room. With HEPA-FILTER for air supply.
• Sick people are not allowed to visit the patient.
• Pets and plants are also not allowed.
51
ISOLATION
•The risk of infection transmission may be highest before a definitive diagnosis can be
reached, therefore, patients with certain clinical syndromes should be isolated
empirically until we have a definitive diagnosis.
EMPIRIC ISOLATION
EXAMPLE:
1. Patient with previous admission of MRSA from Diabetic Foot
Should be under EMPERIC CONTACT ISOLATION until Laboratory
Result of wound swab is received, if it is Positive continue the Contact Isolation; if
Negative discontinue the isolation
* So we can implement EMPERIC CONTACT/ DROPLET/ AIRBORNE according to
patients clinical signs and symptoms.
52
ISOLATION
53
Blood borne pathogen transmitted to Health Care Personnel (HCP) through activities
that involve percutaneous (i.e., puncture through the skin) or mucosal contact with
infectious blood or body fluids.
Occupational Exposures definition:-
A percutaneous injury or contact of mucous membrane or non-intact skin
WITH
• Blood ,tissue and body fluids
• Semen and vaginal secretions
• CSF, synovial , pleural , peritoneal , pericardial , and amniotic fluid
* Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not
considered potentially infectious unless they contain blood.
Management of Occupational
Exposures
Hepatitis B virus (HBV)
Hepatitis B virus (HBV) is ahepadnavirus .It is a double stranded DNA virus. It is found
in highest concentrations in blood and in lower concentrations in other body fluids
(e.g., semen, vaginal secretions, and wound exudates).
1. Risk for Occupational Transmission of HBV
The risk of developing clinical hepatitis if the blood was
both hepatitis B surface antigen (HBsAg)- and HBeAg-
positive was 22%--31%; the risk of developing serologic
evidence of HBV infection was 37%--62%.
The risk of developing clinical hepatitis from a needle
contaminated with HBsAg-positive, HBeAg-negative
blood was 1%--6%, and the risk of developing serologic
evidence of HBV infection, 23%--37% (26).
2. Hepatitis B Vaccination
Health Care Personnel (HCP) who performs tasks involving contact with blood, other
body fluids, or sharps are at on-going risk for occupational exposures to blood borne
pathogen.
54
a. All HCP should receive 3 doses of Hepatitis B vaccine, given at 0, 1,6 series. 1--2
months after completion of vaccination series they should be tested for anti-HBs.
HCP consider immune (responder) if anti-HBs >10 mIU/mL.
b. HCW who do not respond to the primary vaccine series (i.e., anti-HBs <10 mIU/mL)
should complete a second 3 dose vaccine series or be evaluated to determine if they
are HBsAg-positive.
c. Revaccinated persons should be retested for anti-HBs, at the completion of the
second vaccine series. Persons who do not respond to an initial 3 dose vaccine series
have a 30% - 50% chance of responding to a second 3 doses series.
Hepatitis C virus (HCV)
It is a single stranded RNA Flavi virus.
1. Risk for Occupational Transmission of HCV
The average incidence of anti-HCV sero-conversion after
accidental percutaneous exposure from an HCV-positive
source is 1.8% (range: 0%--7%). Transmission rarely occurs
from mucous membrane exposures to blood,
In the absence of PEP for HCV, recommendations for post-
exposure management are intended to achieve early
identification of HCV infection and, if present, referral for
evaluation and treatment options, short course of
interferon started early in the course of hepatitis C is
associated with a higher rate of resolved infection than
that achieved when therapy is begun after chronic
hepatitis C has been well established.
Human Immunodeficiency Virus (HIV)
It is a retroviruses with 2 single stranded RNA.
2. Risk for Occupational Transmission of HIV
The average risk of HIV transmission after a percutaneous
exposure to HIV-infected blood has been estimated to be
approximately 0.3% (95% confidence interval [CI] = 0.2%--
0.5%) and after a mucous membrane exposure,
approximately 0.09%.
MANAGEMENT OF OCCUPATIONAL EXPOSURES
55
The risk for HIV infection was found to be increased with
exposure to a larger quantity of blood from the source
person as indicated by:-
a. A device visibly contaminated with the patient's
blood.
b. A procedure that involved a needle being placed
directly in a vein or artery.
c. A deep injury with hollow-bore needles.
d. Exposure to blood from source persons with
terminal illness.
Post exposure management
1. Treatment of an Exposure Site
Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. Irrigate eyes with clean water, saline. Wound is allowed to bleed but do not squeeze. Deal with the wound site e.g. if suture is needed.
2. Exposure Report
Report the incident to your supervisor.
In addition to electronic OVR, Sharp injury and body fluid exposure notification KKUH
form should be filled properly.
3. Immediately seek medical treatment
During duty hours HCP can receive medical management at EHC .However after duty
hours exposure management will be through DEM.
4. Evaluation of the Exposure Source
The source of the incident should be evaluated for HBV, HCV, and HIV infection
(Hepatitis B markers, anti– HCV, anti – HIV).
If the exposure source is unknown or cannot be tested, information about where and under what circumstances the exposure occurred should be assessed epidemiologically for the likelihood of transmission of HBV, HCV, or HIV.
MANAGEMENT OF OCCUPATIONAL EXPOSURES
56
5. Evaluation of the HCW
Screen the Health Care Worker for Hepatitis B Marker, anti- HCV, anti – HIV
and LFT if the Source is HCV positive
MANAGEMENT OF OCCUPATIONAL EXPOSURES
57
Management of exposure to HBV Source
Post Exposure Prophylaxis (PEP) should be started as soon as possible after exposure
(preferably within 24 hours). The effectiveness of Post Exposure Prophylaxis when
administered >7 days after exposure is unknown.(See the summery in the table)
Management of exposure to HCV Source
1. Perform baseline testing for anti-HCV and ALT
2. Earlier diagnosis of HCV infection is desirable. Perform testing for HCV RNA (R-T PCR
QUALITATIVE AND QUANTITAVE)2-6Ws.
3. Perform follow-up testing (e.g., at 4 & 6 months) for anti-HCV and ALT.
4. Confirm all anti-HCV positive results
MANAGEMENT OF OCCUPATIONAL EXPOSURES
58
Management of exposure to HIV Source The use of PEP should be decided on a case-by-case basis, after considering the type of
exposure and the clinical and/or epidemiologic likelihood of HIV infection in the
source. If these considerations suggest a possibility for HIV transmission and HIV
testing of the source person is pending, initiating a two-drug PEP regimen until
laboratory results have been obtained and later modifying or discontinuing the
regimen accordingly is reasonable.
The following are recommendations regarding HIV post-exposure prophylaxis:
1. If indicated, start PEP as soon as possible after an exposure.
2. Reevaluation of the exposed person should be considered within 72 hours post-
exposure, especially as additional information about the exposure or source person
becomes available.
3. Administer PEP for 4 weeks, if tolerated.
4. If a source person is determined to be HIV-negative, PEP should be discontinued.
5. Postexposure follow-up counseling, testing, and medical evaluation should be
performed. HIV-antibody testing should be performed for at least 6 months
postexposure (e.g., at 6 weeks, 12 weeks, and 6 months).
6. Extended HIV follow-up (e.g., for 12 months) is recommended for HCP who
become infected with HCV following exposure to a source co-infected with HIV and
HCV.
Management of Occupational Exposures to
Mycobacterium Tuberculosis
Transmission of Mycobacterium
tuberculosis (M. tuberculosis [TB] in health
care facility is most likely to occur from
patients who have unrecognized infectious
pulmonary or larynx-related TB, are not on
effective anti-TB therapy, and have not been
placed in Airborne isolation, particularly
during the performance of aerosolized
procedures such as bronchoscopy and
sputum induction. TB can spread through the
air and can travel long distances.
MANAGEMENT OF OCCUPATIONAL EXPOSURES
59
TB CONTROL PROGRAM
Baseline screening should be done at the time of hire.
1. A two-step Tuberculin Skin Test (TST) should be performed as a part of pre-employment check up. When the initial TST is negative, a second test will be done within 3 weeks after the first.
2. Screen HCP at risk annually (i.e., symptom screen & TST for HCWs with baseline negative results).
Health Care Worker Post Exposure Screening
1. If the HCP is converter recently, preventive therapy should be considered. 2. Chest radiograph are performed ONLY on those with recently positive TST and
symptomatic.
Management of Varicella-Zoster Exposure
Patients are most contagious from 1-2 days before the onset of rash. Contagiousness persists until crusting of all lesions (usually about 5 days) and is more prolonged in patients with altered immunity.
Immunization
Routine varicella immunization is recommended for all non-immune health care workers (2 doses with 4-8 weeks in between). Serologic testing for immunity is not necessary because 99% of adults are seropositive after the second vaccine dose.
Varicella – zoster virus (VZV) is a member of the herpes virus family.It is usually a benign childhood disease and it is one of the most readily communicable diseases,( By airborne and contact route ) Zoster has a lower rate of transmission (by contact route )
MANAGEMENT OF OCCUPATIONAL EXPOSURES
60
.1 Varicella vaccine
Staff who are non-immune or whose status is unknown must be evaluated by employee
health clinic immediately. If staff is immune no further action will be taken. If found to
be non-immune, he/ she can be offered varicella vaccine if still within 3 days of
exposure
2-Work restriction
Remain off work from days 10-21 post exposure
3-Varicella zoster immunoglobulins (VZIG)
VZIG is recommended for susceptible pregnant women. (There is no assurance
that VZIG will prevent congenital malformations in the fetus, but it may modify
varicella severity). It should be given within 96 hrs from exposure.
Hospital exposure: Defined as:-
A. Varicella Face to face contact with an infectious staff member or patient (for 5 or more minutes).
B. Zoster: Intimate contact (e.g. touching or hugging) with a contagious person with exposed zoster lesion)
Control Measures
Notify infection control department
MANAGEMENT OF OCCUPATIONAL EXPOSURES
Cleaning, Disinfection, Sterilization
in the Health Care Setting
Historical background • The scientific use of disinfection and sterilization methods originated more than 100 years ago • Ignatz Semmelweis (1816-1865) and Joseph Lister (1827-1912) are important pioneers for the promotion of infection control.
Ignatz Semmelweis (1816-1865) More than 100 years ago, Semmelweis demonstrated that routine handwashing can prevent the spread of disease
• He worked in a hospital in Vienna when maternity patients were dying an alarming rate
• He recognized that medical students worked on cadavers during an anatomy class and afterwards they went to the maternity ward.
• Students did not wash their hands between touching the dead and the living!!! • After administrating the hand washing before examining the maternity patients
the mortality rate decreased Definition of terms
Joseph Lister (1827-1912) Lister, for the first time, used carbolic acid in operating theatres that significantly
reduced mortality rates. Later when it was accepted that microorganisms were the causative agents of
infections in 1867, Lister introduced British surgery to hand washing and the use of phenol as antimicrobial agent for surgical wound dressings
His principles were gradually adopted in Britain and later in US, and this was the beginning of infection control
61
Definition Of Terms: Aseptic techniques Prevent microbial contamination of materials or wounds. Antisepsis Disinfection of living tissues (e.g., in a wound), achieved through the use of antiseptics. Antiseptics Are applied (do not kill spores) to reduce or eliminate the number of bacteria from the skin. Cleaning The removal of adherent visible soil, blood, protein substances (tissue) and other debris from surfaces by mechanical or manual process. It is generally accomplished with water and detergents. Removes or eliminates the reservoirs of potential pathogenic organisms. Disinfection A process that kills most disease-producing microorganisms. Disinfection does not destroy all bacterial spores. Medical devices must be cleaned thoroughly before effective disinfection can take place. There are 3 levels of disinfection; high, intermediate and low. Decontamination The process of cleaning, followed by the inactivation of microorganisms, in order to render an object safe for handling. Detergent A synthetic cleansing agent that can emulsify oil and suspend soil. A detergent contains surfactants that do not precipitate in hard water and may also contain protease enzymes and whitening agents. Disinfectant A chemical agent that kills most disease-producing microorganisms, but not necessarily bacterial spores. Disinfectants are applied only to inanimate objects. Some products combine a cleaner with a disinfectant. Enzymatic Cleaner A cleaning agent that contains enzymes which break down proteins such as blood, body fluids, secretions and excretions from surfaces and equipment. Most enzymatic cleaners also contain a detergent. Enzymatic cleaners are used to loosen and dissolve organic substances. Sterilization The process by which all forms of microbial life, including bacteria, viruses, spores and fungi are destroyed
62
CLEANING DISINFECTION STERILIZATION
Spaulding System
Categorizes how an object is disinfected by how the object is used:
Critical Semi-critical Non-critical
Spaulding
Classification of Objects Application
Level of Germicidal Action Required
Critical Entry or penetration into sterile tissue,
cavity or bloodstream Sterilization
Semi-critical Contact with mucous membranes, or
non-intact skin High-level Disinfection
Non-critical Contact with intact skin Low-level Disinfection
CRITICAL MEDICAL DEVICES
Used on or in sterile areas of the body Require sterilization
• Cutting or dissecting devices
• Microsurgical instruments
• Cardiac catheters
• Implantables
• Dental Instruments
SEMI-CRITICAL DEVICES
Used in or on mucous membranes or damaged skin
Require sterilization or high-level disinfection
• Flexible endoscopes
• Laryngoscopes
• Endotracheal tubes
• Vaginal speculums
• ENT exam instruments
63
NON- CRITICAL DEVICES
May come into contact with patient’s intact skin
Requires Intermediate or low-level
disinfection
Non-critical Patient Care Items
• Bedpans
• Blood pressure cuffs
• Crutches
• Computers
Non-critical Environmental Surfaces
• Bed rails
• Bedside or overbed tables
• Nurse call buttons
• Furniture in patient rooms
• Floors
SPAULDING SYSTEM
64
Cleaning shall be done manually or using mechanical cleaning machines (e.g., washer-disinfector, ultrasonic washer) after gross soil has been removed. Automated machines may increase productivity, improve cleaning effectiveness and decrease staff exposure to blood and body fluids. Rinsing Rinsing following cleaning is necessary to remove loosened soil and residual detergent. Drying Drying is an important step that prevents dilution of chemical disinfectants which may render them ineffective and prevents microbial growth:
Follow the manufacturer’s instructions
for drying of the device
*Cleaning of the object;
properly cleaned items
enhance better quality
of disinfection
Cleaning of Medical Instruments
Pre-Cleaning of Medical Devices at Point of Use
Pre-cleaning (e.g., soak or spray) prevents soil from drying on devices and it makes them easier to clean: Cleaning products used should be appropriate for
medical devices and approved by the device manufacturer
PPE shall be worn for handling and cleaning contaminated devices.
65
Disinfection
1. Noncritical medical devices shall be low-level disinfected prior to use.
2. Semi-critical medical devices shall be, at a minimum, high-level disinfected prior to use, sterilization is preferred.
3. Disinfectant manufacturers shall supply compatibility information for the disinfectant to ensure that it is compatible with the medical devices on which it will be used.
4. Manufacturer’s instructions for installation, operation and ongoing maintenance of thermal disinfection equipment shall be followed.
5. A permanent record of disinfecting parameters shall be maintained.
Principles of Disinfection
Disinfectant Advantages Disadvantages
Sodium
hypochlorite
(household bleach)
Inexpensive, Fast-acting,
widely available. Active
against bacteria, spores,
MTB, viruses
Odor can be irritating. Corrosive to
metals, inactivated by organic
material. May discolor fabrics
Ethyl or isopropyl
alcohol (70-90%)
Inexpensive, widely
available, rapidly
effective. Active against
bacteria, MTB, viruses
Not effective against bacterial spores
Not for large surfaces
Quaternary
ammonium
compounds
Not too expensive,
widely available. Good
cleaning agents
Not effective against bacterial spores,
MTB, non-enveloped viruses. May
become contaminated
Phenolics Widely available Use on bassinets may be toxic to
infants
Poor activity against bacterial spores
and non-enveloped viruses
The use of single-use (disposable) cleaning tools is recommended.
The destruction of harmful microorganisms, usually other than bacterial spores, on inanimate objects by the use of a chemical agent.
66
DISINFECTANT USED IN KKUH
Quaternary Ammonium Compound (QAC)
(AzoActive™)
Use: for low level disinfection of non-critical surfaces and items Areas Round: All over KKUH Advantages: • Readily available • Does not cause damage to surfaces • Most commonly used in the health care setting Disadvantages: • Can be easily contaminated • Can cause contact dermatitis
DISINFECTION
67
Sodium Hypochlorite Granules & Tablets
(Precept™)
Use: for low to intermediate level disinfection of surfaces and items Areas Found: All over KKUH (dirty utility stock item) Disinfectant of choice for blood and body fluid spillage
Peracetic Acid +Hydrogen peroxide (Puristel™)
Use: for high level disinfection of dialysis machines Areas found: RDU
DISINFECTION
68
Summary of recommendations for disinfection of contaminated medical
devices:
1. Contaminated devices shall not be transported through areas designated for
storage of clean or sterile supplies, client/patient/resident care areas or high-
traffic areas.
2. Sterile and soiled devices shall not be transported together.
3. Reusable medical devices shall be thoroughly cleaned before disinfection or
sterilization.
4. If cleaning cannot be done immediately, the medical device should be pre-
treated to prevent organic matter from drying on it.
DISINFECTION
69
STERILIZATION
Is the destruction of ALL forms of life, including the bacterial spores, viruses, prions. There are no degrees of sterilization, e.g. high level, low level. It is an all-or-nothing process.
Sterilization Technologies
• Steam autoclaving
• Ethylene oxide gas
• Glutaraldehyde
• Ortho-phthalaldehyde (OPA)
• Plasma-phase hydrogen peroxide
• Peracetic acid
• Flash
• Ozone
Factors Affecting Sterilization or Disinfection
• Amount of organic material
• Number of microorganisms
• Type of microorganisms (resistance levels)
• Type of germicidal agent
• Concentration of germicidal agent
• Exposure time to germicidal agent
• Temperature of exposure
• pH of solution
• Presence or absence of moisture
“Flash” Sterilization
• In hospitals, unwrapped item(s) are run through a sterilization cycle using a higher temperature and a shorter exposure time
• Items used immediately after cool-down
• Do not use flash sterilization for implanted devices
• Avoid using flash sterilization if possible
• Have adequate instrument inventory
70
• Highly efficacious
• Bacteriocidal, sporicidal, tuberculocidal, fungicidal, virucidal
• Rapid activity
• Achieves sterilization quickly
• Strong permeability
• Penetrates packaging materials and device lumens
• Materials compatibility
• Negligible changes in either appearance or function of processed items
Attributes of the Ideal Sterilant*
Non-toxic Poses no health hazards to the operator, patient, or the environment
Organic material resistance Withstands reasonable organic challenge without loss of efficacy
Adaptability Monitoring capability
Physical, chemical, or biological indicators Cost effective
General Points to Consider
• Cleaning:
• Was this done, automated or manual, what cleaning chemical, use conditions
• Rinsing:
• Use of tap water, removal of residuals, water quality
• Sterilization/disinfection:
• Label instructions, contact time, factors affecting the operation of equipment, water quality, inappropriate use/misuse of disinfectants, drying of the instrument
• Equipment use during medical procedures:
• Use of tap water, reuse of single-use devices, multi-dose vials, examine all instruments/devices available for use
• Documentation:
• Instrument identification noted in charts, processes used, instrument trace back
STERILIZATION
71
72
73
74
75
76
77
Notification of Infectious diseases Notification of infectious diseases is one of the basic element of the surveillance system which is the corner stone in the control and prevention of infectious diseases. Notification Definition Notification is the process of informing the Health Authorities (Ministry of Health) about the occurrence of a disease/condition that should be notified. All patients diagnosed with one of the diseases listed below must be recorded by the Infection Control Staff who will forward that information to the Chairman of Infection Control Committee and then to the Chief of Staff. Objectives of Notification 1. To identify the public health problems. 2. To take preventive and control measures against infectious diseases. 3. To allocate the necessary resources to solve major health problems. 4. To identify the epidemiological change for the disease. 5. To help eradication of some diseases.
Types of Notification
Immediate Reporting (24 Hours)
This is for diseases that need immediate action, notification done by fax or telephone.
a. Meningitis
b. Guillian Barre Syndrome
c. Food poisoning
d. Chemical poisoning
e. Measles
f. Mumps
g. Rubella
h. H1N1
i. MERS- CoV
j. Viral Hemorrhagic Fever
Ministry Of Health
NOTIFICATION
78
Weekly Reporting
Infectious Diseases should be notified weekly to the Region Health Authority and
then monthly reported to Ministry of Health.
a. Tetanus, other
types
b. Whooping cough
c. Measles
d. Mumps
e. Rubella
f. Congenital Rubella
g. Hepatitis A,B,C
h. Unspecified
Hepatitis
i. Brucellosis
j. Rabies
k. Salmonellosis
l. Shigellosis
m. Amoebic
Dysentery
n. Typhoid and
paratyphoid fevers
o. Chicken poxo.
p. Echinococcus
Hydatid disease
q. Puerperal fever
r. Hemolyticuraemic
syndrome
s. Scorpion bites
t. Syphilis
u. Gonorrhea
v. Scabies
This includes all infectious diseases notified to the Regional Health Affairs which in turn notifies the Deputy Minister for Preventive Medicine. It also includes reports of vaccination, malaria, tuberculosis and other reports as specified by the Ministry of Health.
Monthly Reporting
NOTIFICATION
79
GCC- CIC Manual RED BOOK
For More Information:
Please Contact 469-93-52 KKUH- INFECTION CONTROL DEPARTMENT
REFERENCE
80
![CTF Vortrag Brenner - Handout - sfb991.uni-duesseldorf.de · indefinite definite possessive individual– IC pope earth weather Police indefinite definite possessive relational [+R]](https://img.pdfslide.us/doc/110x75/5e0cf498b4c71f10ff4e3e06/ctf-vortrag-brenner-handout-indefinite-definite-possessive-individuala-ic.jpg)
